1396774121 NPI number — SUSAN MANIFOLD N.P.

Table of content: SUSAN MANIFOLD N.P. (NPI 1396774121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396774121 NPI number — SUSAN MANIFOLD N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANIFOLD
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396774121
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6804 CECELIA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW PORT RICHEY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34653-4935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-232-0644
Provider Business Mailing Address Fax Number:
888-546-0488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 E 9TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80220-3706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-372-0000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  140116 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)